INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 31, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection VRL667011 Bridgeway House was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
|
Plan of Correction
|
§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on review of the staff records the recovery house failed to provide a mechanism to collect feedback for completed trainings
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Facility Director will develop and implement a new, more comprehensive "Training Feedback Form" to replace the current version, ensuring it captures detailed input on training content, presenter effectiveness, and applicability to job duties. The House Manager will distribute the form immediately following all trainings, collect completed forms, and review them with the Facility Director to identify any areas for immediate improvement. The Facility Director will maintain all feedback forms on file for review during inspections and will oversee the process to ensure it is completed after every training.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain the improved feedback collection process for all future trainings.
|
§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
|
Observations
Based on a review of resident records, the recovery house failed to maintain an individual record for each resident which must include: All records obtained under 717.22.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Facility Director will review all current resident files to ensure that each contains all records required under 717.22. Any missing documentation will be obtained and added immediately. The House Manager will use an updated resident record checklist during intake and throughout the resident's stay to confirm all required records are collected and filed. The Facility Director will review each new resident file within 7 days of intake to verify completeness and will perform quarterly audits of all active files to ensure ongoing compliance.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain complete individual resident records for all current and future residents. |
§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
|
Observations
Based on a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Facility Director will ensure that the existing policy requiring emergency contact notification is fully enforced. The policy states that the House Manager must make at least one documented attempt to notify the resident's emergency contact within 12 hours when a resident decides to end residency or does not return as expected. If the initial attempt is unsuccessful, the House Manager must make a second documented attempt within one week of the first attempt. All attempts will be recorded in the resident's file with the date, time, method, and outcome. The Facility Director will review all applicable resident files within 48 hours of case closure to confirm that the required contact attempts were made and documented.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain enforcement of the existing emergency contact notification policy for all applicable cases.
|
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
|
Observations
Based on the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
The Facility Owner will ensure that every floor containing resident bedrooms has a minimum of two unobstructed exits separated by at least 15 feet. Any ladders or fire escapes located above the ground floor will be securely affixed to the house. All rooms, including bedrooms with exits, will remain unlocked and accessible to all residents in case of emergency. Immediate corrective actions will include clearing any obstructions from exits, securing exterior ladders or escapes, and verifying that all applicable doors remain unlocked during occupancy. The House Manager will conduct monthly walk-throughs to confirm continued compliance and will immediately report any safety concerns to the Facility Owner for correction.
Person(s) Responsible: Facility Owner, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain proper exit access and safety measures on an ongoing basis.
|